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Combining Robotic Surgery and the CO2 Laser for Optimal Results

By Thiers Soares Raymundo, MD

In gynecologic endoscopy, two technologies – the CO2 laser and surgical robot – are changing how we approach an increasing number of procedures. I have been using these technologies for two years for several surgeries, including myomectomy for uterine fibroids, endometriosis and cystectomy.

The benefits of using these technologies in combination are most pronounced, however, in the surgical eradication of endometriosis. Each offers unique advantages for endometriosis. The CO2 laser offers fine control of ablation or excision that preserves underlying tissues, including the ovaries, while the robot provides optimal visualization and maneuvering inside the abdomen. Together, they make the perfect combination for complete treatment of this condition.

Advantages of the CO2 Laser
Using the Lumenis UltraPulse Duo CO2 laser, I can remove thin or thick layers of endometrial cells without damaging underlying tissue structures. Based on laser settings and the fibrosity of tissue, I can estimate the sub-millimeter depth of penetration, thus preventing thermal injury and resulting complications.

This capability is particularly advantageous when endometriosis compromises the ovaries. I can apply the laser, ablate the endometrial cells, and stop the bleeding without harming the ovaries. With the ovaries intact, patients have far less risk of infertility in the future.

Postoperatively, my patients have pain and recovery similar to other endoscopic methods, and much better than an open robotic approach. Outcomes, length of stay, pain, and complications with this minimally invasive approach are all well within our goals for a safe, effective procedure that allows patients to quickly return to their daily lives.

Advantages of a Robotic Approach
In robotic CO2 laser surgery for endometriosis with my da Vinci System, I can access endometriosis throughout the abdomen through three small incisions. Visualization is excellent, with the scope’s 3D view magnified in HD – nothing like the difficulty associated with open surgery. The goal of endometriosis surgery is to remove every trace of endometrial cells, and when I can see better, I can treat better.

Another advantage of the robot is its movement and dexterity, which far exceed human hands. The instruments bend in virtually any angle and direction, affording access to all the areas in the abdomen where endometrial cells are located. The system makes surgery comfortable for the surgeon and reduces the duration of surgery as well.

Combining the Two Technologies
The combined advantages of these technologies enable surgeons to access and clearly see and evaluate all the endometrial cells, and then ablate them with minimal damage to underlying tissue, including the ovaries. What’s more, it’s easy to learn to perform robotic surgery, compared to standard laparoscopy. Surgeons usually need only a few repetitions to learn the technique.

Similarly, surgeons beginning to use the CO2 laser quickly learn to control the depth of ablation, so they are soon prepared to remove superficial lesions on the bladder or bowel without inducing complications. For treatment of endometriosis, these two technologies seem to truly be made for each other.

Thiers Soares Raymundo, MD, is Head of the Gynecological Endoscopy Service at State University of Rio de Janeiro; Head of the Gynecological Endoscopy Service at Federal Hospital Cardoso Fontes, Rio de Janeiro; Vice-President of SOBRACIL-RJ (Brazilian Society of Laparoscopic and Robotic Surgery) and International Board Member of the Society of Laparoendoscopic Surgeons.

The content presented on this page is provided for informational and/or educational purposes. This material represents the views and opinions of its authors and should not be construed as representing or reflecting the official position, views or opinions of the Society of Laparoendoscopic Surgeons. The authors of the work are solely responsible for its content.

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